At the North American Spine Society Annual Meeting last month, David W. Polly Jr., MD, discussed the details of reimbursement models important to spine care and gave an update on his experience with the existing and evolving models of care.
"Pay for value is the concept that is clearly sweeping the nation right now instead of fee-for-service," said Dr. Polly. "There are concepts of bundled payment, accountable care organizations and integrated clinical networks are being bantered around. The take home message is that he who makes the contract and receives the payment makes the pay out. So whoever it is that is going to take the risk and write the contract is the person who is going to determine what the distribution of the resources will be."
The concepts are still uncertain, but it seems clear that the party taking the risk will receive the payout. However, this party is still responsible for the shortfall when complications occur. Dr. Polly discussed his situation in Minnesota where healthcare organization HealthPartners has developed guidelines for covering spine care.
"The concept that is being most aggressively explored right now is the concept of shared savings between payers and healthcare systems. This is sort of like gain sharing at a mega scale and if we can find a way to generate a savings through some innovation or process of care, that savings should be allocated between the people who are contracting and the people who are generating the savings," said Dr. Polly.
HealthPartners in Minnesota is adapted the gatekeeper approach of medical spine management using performance metrics for both specialists and primary care physicians. The focus is medical spine management. They looked to find the greatest expense and discovered it wasn't in surgery but care management. As a result, Health Partners has developed initiatives to:
• Reduce imaging
• Limit opioid use
• Limit epidural steroid injections
• Define the appropriate timing of services
• Mandate periods of physical therapy before surgery
• Require patients see a medical spine specialist before seeing a surgeon
While HealthPartners has taken an extreme approach to developing treatment algorithms, payers across the country are requiring surgeons collect more information about patients and prove surgery is indicated before they will grant preauthorizations.
"All payers have decided they want to cut back on expensive items. The prior authorizations for lumbar fusions have become rather Herculean," said Dr. Polly. "It is not uncommon for my scheduler to spend eight hours per case trying to get approval. If you do the math, you figure out I am losing money trying to be able to take care of my patients."
Dr. Polly now prints out the preauthorization checklist, tells patients which treatment he would recommend and outlines what the patient needs to do in order to receive coverage from their insurance company for the treatment. Payers are now requiring surgeon offices to document non-operative treatment, radiographic documentation, treatment plan documentation and psychological evaluations among other documentation before receiving approval for surgery.
Dr. Polly closed by telling surgeons in other regions what to expect if the HealthPartners model spreads to payers in other parts of the country.
"Cost pressures for all items of spine care — not just surgical — anything that is an item of expense, including medication, is subject to scrutiny," said Dr. Polly. "Documentation of objective patient reported outcome status, which in Minnesota the default has become the Ostwestry index. You've got to document the psychological evaluation. There has been mandated shared decision-making use, but it's been unclear what constitutes that so that has been a challenge as well…The final take home message is that it's a risk sharing approach and if you aren't sharing the risk, the goal of the payer is to take you out of the equation."
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